Transcript this resource

Sue Fortune and Karen Poffenroth
Reasons for High Co-morbidity Rates of
Severe Mental Illness and Substance Abuse
Biological sensitivity, genetic and early
environmental events, interact with
environmental stress to precipitate the
onset of psychiatric disorder or to
trigger relapses
• Substances can increase vulnerability
• Smaller amounts of substances result in problems
• “Normal” substance use is problematic for clients with
severe mental illness but not in general population
Outcomes
 IDDT Model increases likelihood of abstinence
 Fidelity to IDDT Model improves abstinence outcomes
 Abstinence correlates to other positive outcomes
IDDT: Basic Principles
 Integration of treatment
 Assertive engagement
 Comprehensiveness of services
 Stage wise treatment
 Time unlimited services
Substance-Related Disorders
 Substance-Related Disorders
 Refers to maladaptive behavior associated with regular
use of substances
 Challenge is to distinguish use, abuse, dependence
 Two categories of Substance-Related Disorders
 Substance Use Disorders: (Substance Dependence & Substance
Abuse)
 Substance –Induced Disorders
DSM-IV Definitions
of Substance Use Disorders
 Use--use without causing problems
 Abuse--use for 12 months despite causing problems





Failure to fulfill major role obligations
Use in hazardous situations
Legal problems
Social – Interpersonal problems
Has control – poor decision making
Dependence Substance Use Disorders
 Dependence--use for 12 months resulting in 3 or
more of the following:






Tolerance
Withdrawal
More amount or time than intended
Desire to cut down
Other activities reduced
Use despite problems
 Psychological dependence
 Physical dependence – development of tolerance to effects
of substance, withdrawal symptoms following cessation of
substance use, use of substance to decrease withdrawal
symptoms.
Clinician Rating Scales
Clinician 5 point rating scale to determine severity of use
based on worst use within last six months

Consistent with diagnostic classification (DSM IV)

Based on team consensus

Be data driven/avoid assumptions

Use multiple sources of assessment
Clinician Rating Scales
Method of Discrimination
1. Abstinence
2. Use without impairment
3. Abuse (severity of problems lasting at least
one month)
4. Dependence (3 types of evidence)
5. Severe dependence (use contributed to
more than one institutionalization or three of six
months institutionalized)
Role Play
 Get into pairs (clinician, client – use an actual client)
 Using the Alcohol or Drug Use Scale, rate the clients
drug or alcohol use (ie, use, abuse, dependence)?
 What are the indicators for that diagnosis?
SUBSTANCE ABUSE, MENTAL ILLNESS, OR
DUAL DISORDERS?
 It is often difficult to figure out whether alcohol abuse causes




depression and anxiety or whether these symptoms are due to a
separate and distinct co-occurring disorder.
If the symptoms are caused by drinking, they should go away within
one month of becoming abstinent (no alcohol or other substances at
all).
Clinicians should look for periods of abstinence in the client’s life and
ask the client whether depressive or anxiety symptoms were present
during that time.
Including family or supports in the assessment can help you get an
accurate history. They may be able to remember a client’s symptoms
and level of function during periods of sobriety better than the client
can.
Tanya’s year-long period of abstinence is incredibly valuable
information. It was during this period that she experienced a postpartum depression, strongly suggesting that her depressive illness is
distinct from her alcohol dependence.
ETOH, Anxiety and hypnotic sedatives
 People with alcohol and anxiety problems are often prescribed




sedative-hypnotic medications (such as the benzodiazepine,
clonazepam) for their anxiety.
Use of these kinds of medications may make the alcohol problem
worse and lead to abuse, however, because they have a similar effect on
the brain as alcohol (they are “cross reactive”).
Benzodiazepines, in particular, tend to be overused and abused in the
same way as alcohol.
Once a person is taking a sedative-hypnotic medication regularly, he or
she may have a hard time stopping it because they experience
increased anxiety and withdrawal symptoms when they do.
For some individuals with severe anxiety, the use of benzodiazepines
might be necessary, but experts believe that antidepressant
medications, which are very effective for treating anxiety, and
behavioral treatments should be tried first.
Meds for ETOH abuse and dependence








Other medications can be helpful when they are used in combination with integrated dual disorders
treatment.
Disulfiram (Antabuse), causes a very uncomfortable physical reaction if a person drinks while taking
it. Disulfiram is intended to help clients avoid taking a drink because they want to avoid the toxic
reaction they will get to alcohol when they have disulfiram in their system.
The medication provides a psychological barrier to drinking. Many clients will drink soon after
starting disulfiram. Experiencing a disulfiram-alcohol reaction may help them avoid drinking in the
future.
Disulfiram is most effective if it is monitored: someone should watch the client take the medication
to be sure they actually take it. Practitioners or staff can observe clients take disulfiram on some days
or family members can provide even more frequent supervision.
Naltrexone (Revia) is an opiate antagonist that blocks the effects of certain natural chemicals in the
brain and thereby reduces craving for alcohol.
Like disulfiram, naltrexone does not have abuse potential.
Naltrexone helps to reduce craving for alcohol as clients are trying to reduce their alcohol use. There
are no symptoms and no danger to clients if they use alcohol while taking naltrexone, so this
medication is appropriate for clients who are still drinking and have not yet developed a strong
commitment to sobriety.
Naltrexone also blocks the effects of opiate drugs like heroin and morphine. It can be used to treat
people with opiate abuse or dependence.
Stages of Change
Stages of Treatment
 Pre-contemplation
 Pre-Engagement
 Contemplation
 Engagement
 Preparation
 Early Persuasion
 Action
 Persuasion
 Maintenance
 Early Active Treatment
 Late Active Treatment
 Relapse Prevention
 Remission/Recovery
Pre-Engagement/Engagement
 Engagement is the stage when the client has no relationship with a
 treatment provider.
 The client typically does not consider substance use or mental illness symptoms a
problem.
 The clinician's job is to help the client get engaged in treatment.
 They engage the client by providing helpful outreach and practical assistance to help the
client face immediate challenges, such as health problems, financial problems, and so on.
 Clinicians develop a working-together relationship with the client during this phase by
providing help and by using good listening skills and motivational interviewing
techniques
 Clinicians do not confront clients about their substance use during this stage,
though they do try to complete a basic assessment of the substance use.
 As regular contact with the clinician occurs, the client may progress to the persuasion
stage.
 Which clients are in this Treatment Stage?
Early Persuasion/Persuasion
 As the working relationship develops, if the client does not perceive, acknowledge, or
understand his or her substance use or mental illness symptoms, the client is in the
persuasion stage.
 The clinical task is to help the client think about the role of substance use in his or her
life.
 Active listening, exploratory questions about experiences and goals, and education are
common techniques.
 These techniques (motivational interviewing), are designed to help the client think
about life goals, substance use, mental illness symptoms, and whether substance use or
symptoms get in the way of achieving life goals.
 During this stage, a detailed functional assessment of substance use can be completed
 During this and later stages, it is often helpful to meet with family members to provide
education, get input and include the family in treatment.
 What other techniques are used in this Stage of Treatment?
 Which clients are in this stage?
Early/Late Active Treatment
 Once the client recognizes that substance use is a problem and decides




to reduce or stop his use altogether, the client is in the active treatment
stage and the goal is to acquire additional skills and supports.
For example, the client may need skills to avoid substances (such as
assertiveness skills), to socialize without substances (social skills), and
to manage feelings without substances (stress management
techniques).
He or she may need new friends, a better relationship with family, and
a support group like Alcoholics Anonymous or SMART Recovery.
Helping the client to learn skills and find supports is called active
treatment.
Which clients are in this Stage of Treatment?
Relapse Prevention/Remission
 When the client is in stable remission (at least six months
without substance abuse), the task is to avoid relapsing
back into problematic substance use.
 The clinician can help with a relapse prevention plan,
which examines triggers to use substances, such as feelings,
people, or situations, and specifies new ways to avoid or
handle these cues.
 Another common task during relapse prevention is to
facilitate further recovery by developing other healthful
behaviors and pleasurable activities.
 Which clients are in this Stage of Treatment?
Progress through the Stages of Tx.
 Most people move through each stage while making progress towards




recovery.
Some people move steadily, others move in fits and starts, some move
very slowly.
People often relapse and move backwards and then forwards again.
The important point for you to understand is that when people receive
integrated dual diagnosis treatment, the treatment needs to
correspond to the stage of treatment.
In other words, it does little good to work on active treatment skills if
the client is not acknowledging a problem with substance abuse. It
makes much more sense at that stage to engage the client in a helping
relationship and to use motivational counseling to explore the client’s
experience with substance use.
Group work
 Group according to Stage of Treatment and Stage of
Change
 Identify client who is currently in this stage
 Identify strategies that you would when working with
this client.
IDDT Plan
 List psychiatric disorder(s)
 Stage of Treatment/Change
 Problem
 Goal
 Intervention
 Tx modality
 Responsible Clincian
 Chose a client and complete an IDDT Plan